NHS Correspondence handling inquiry

NHS England understated the problem at our evidence session in October 2017 by not disclosing the full extent of the new backlog of clinical correspondence. NHS England told us in October 2017 that there were about 150,000 items of correspondence that needed to be returned to the correct GP, in addition to 12,000 items that transferred from NHS SBS. However by July 2017, it had actually identified a total of 277,000 items of mishandled clinical correspondence and, by November 2017, this had increased to nearly 374,000 items. NHS England now states that the 150,000 represented the number of items of correspondence that it had identified for further triage at that point, having discounted other non-clinical correspondence items that had been identified. However, NHS England should have told us about the full extent of the issue when it first disclosed the problem. It now says that, in fact, it overstated the figure in October 2017, as there turned out to be only 30,328 items that required clinical triage. Furthermore, NHS England led us to believe in October 2017 that the new cases of mishandled correspondence had been discovered as a result of checks that it had carried out following the NHS SBS incident. However, the new correspondence had in fact been identified by Capita and disclosed to NHS England a year before our October 2017 evidence session. Recommendation: NHS England should write to the Committee in November 2018 and again in May 2019 with an update on: • the total number of items of misdirected correspondence identified to date; • the size of the current backlog of unprocessed correspondence; • any new backlogs of misdirected correspondence that have been identified since our March 2018 evidence session; and • an update of its assessment of whether there has been harm to patients.

NHS England has not communicated effectively with GP practices about how they should handle misdirected clinical correspondence. GP practices have been required to return misdirected correspondence to the sender since May 2015, but practices are still sending around 5,000 to 10,000 items to Capita each month in error. NHS England tells us that it has previously communicated the arrangements for handling misdirected clinical correspondence to GPs, but acknowledges that its previous attempts did not have the required effect. It is planning a new communication campaign from May 2018, three years after the new arrangements were put in place. Recommendation: NHS England should set out in its November 2018 update what it has done differently to ensure that its planned communication campaign is more effective than the last, as well as the impact the campaign is having on reducing the volume of correspondence that GPs are sending to Capita in error. 6 Clinical correspondence handling in the NHS

NHS England expects to spend £2.4 million attempting to resolve misdirected correspondence because some GP practices are not handling clinical correspondence correctly. We recognise the pressures that GPs are under but nevertheless they do have staff that are responsible for providing administrative support. NHS England says that, because there is such a large number of practices that are not handling clinical correspondence appropriately, it is not realistic for it to use its powers to intervene in individual cases. In practice, it is not clear whether NHS England has the levers that it needs to ensure that GPs comply with the requirements. NHS England cannot yet identify the worst offending GP practices, but plans to analyse data on which GPs are not complying following its communication campaign in May 2018. It estimates that it will cost £2.4 million to review the new backlog of clinical correspondence for evidence of harm caused to patients as a result of the issue. Recommendation: NHS England should report back to the Committee by November 2018 on what it is doing to identify consistently non-compliant GP practices and how it is going to work with GP representative bodies to ensure GP practices are following the correct correspondence handling procedures.

The problem got worse and remedial action for patients was delayed because it took NHS England too long to escalate the issue internally. NHS England first learnt about the new backlog of correspondence in May 2016, but the issue was not escalated internally until August 2017. It tells us that, between October 2016 and August 2017, its primary care support team reviewed the correspondence to understand the scale and nature of the issue, but that this “took them a fair while”. During this period, the size of the backlog grew as Capita continued to receive clinical correspondence from GPs in error. Capita and NHS England’s initial checks in November 2016 identified 170,000 items of clinical correspondence, but by November 2017 this had reached 373,868. NHS England recognises that the issue was escalated “rather belatedly internally” and is carrying out an internal review of what went wrong. Recommendation: In its November 2018 update, NHS England should set out what it has done to ensure that issues and risks get escalated promptly in the future. Clinical correspondence handling in the NHS 7 1 The scale and impact of the incident

NHS England led us to believe in October 2017 that the new cases of mishandled correspondence had been discovered as a result of checks that it had carried out following the NHS SBS incident. It said that following the NHS SBS incident, it had looked back at the processes used for the correspondence items not processed by NHS SBS on a “belt- and-braces” and “abundance-of-caution” basis. It added that it had also looked at whether GPs had been following the new processes for redirecting clinical correspondence and had identified the new pieces of unprocessed correspondence.9 However, the National Audit Office found that the new correspondence had in fact been identified by Capita and disclosed to NHS England in May 2016 and again in October 2016.10 The impact of the two incidents on patients

NHS England has identified a total of 1,132,043 documents that needed to be reviewed following the NHS SBS incident and discovery of the new backlog of clinical correspondence. So far, it has identified two cases where expert consultant review had concluded that patient harm cannot be ruled out.11 NHS England told us that in one of these cases, the GP has spoken to the patient about a referral that should have taken place. It said that in the other case, the patient is now deceased and NHS England is trying to find the family to inform them of the incident. It told us that it aimed to have dealt with that particular case by April 2018.12

Following clinical review, NHS England has ruled out the possibility of harm to patients for 1,016,378 of the 1,132,043 cases. However, there remain 1,821 outstanding cases where further information, such as clinical notes, is required before the review can be completed. There are also an additional 4,070 cases where NHS England has not yet gained the necessary patient consent to allow it to access the patient’s clinical notes.13 NHS England told us that, in most cases, the GP has attempted to make contact with the patient on a number of occasions, and NHS England has also written to all these patients by recorded delivery to ensure that they had the opportunity to ask for a review. It said that a note had been made on the medical records of these patients to prompt a review when they next contact their GP.14 7 C&AG’s Report, paras 7, 3.7–3.9 8 Q 64 9 Oral evidence taken before the Committee of Public Accounts on 16 October 2017, HC 396, Qq 4, 6 10 C&AG’s Report, paras 4–5 11 Letter from NHS England to Committee of Public Accounts, 22 March 2018 12 C&AG’s Report, Qq 15–17 13 Letter from NHS England to Committee of Public Accounts, 22 March 2018 14 C&AG’s Report, Q22 Clinical correspondence handling in the NHS 9 2 NHS England’s handling of the incident Communicating the arrangements for handling clinical correspondence

Since May 2015, GP practices have been required to return clinical correspondence about patients that are not registered at their practice to the original sender. However, practices are still sending around 5,000 to 10,000 items to Capita each month in error. NHS England told us that it has previously communicated the arrangements for handling misdirected clinical correspondence to GPs, but acknowledged that its previous attempts had not had the required effect.15

NHS England said that it is planning a new communication campaign from May 2018 to ensure that GP practices understand the requirement to return misdirected correspondence to the sender. It noted that it was particularly important that administrative staff working in practices understood this requirement. NHS England said it would not be possible to carry out a targeted campaign, as too many GPs are not following the correct procedure. However, it noted that there are plans to introduce a tagging system which will enable it to produce data on the movement of correspondence, and to be more targeted in its communications in the future.16 Action taken by NHS England in response to non-compliance by GPs

NHS England acknowledged that there was a widespread problem with GP practices not handling clinical correspondence appropriately. It told us that it cannot yet identify the worst offending GP practices, but plans to analyse data on which practices are not complying following its communication campaign in May 2018. It said it would share data on the worst offending GP practices with local offices and clinical commissioning groups that manage its relationship with GPs.17

NHS England told us that because non-compliance is widespread, it is not realistic for it to use its powers to intervene in individual cases. It said it may make use of these powers if it could reduce the number of non-compliant practices.18 In our November 2017 Report we commented that NHS England had given up trying to find out whether any patients had been harmed simply because 2,000 GPs had not confirmed that they had reviewed correspondence about patients, despite receiving payments for the work.19 In response to our questions about whether NHS England has the levers to intervene where GPs had not provided the necessary information, NHS England was reluctant to identify any additional powers it might need. It responded that in this particular incident, it did not need more levers as the “vast majority” of GPs had done what was asked of them.20 15 C&AG’s Report, paras 2, 11; Q44 16 Qq 41–45 17 Qq 45–48, 51; C&AG’s Report, para 9 18 Q 51 19 Committee of Public Accounts, Fourth Report of Session 2017–19, Clinical correspondence handling at NHS Shared Business Services, HC 396, 29 November 2017 20 Qq 54–60 10 Clinical correspondence handling in the NHS Escalating the issue

In May 2016, Capita informed a member of NHS England’s primary care support team that there was a problem with an unquantified accumulation of “clinical notes” (a term which can refer to a range of material, including clinical correspondence). In October 2016, Capita flagged the issue again in a report to NHS England. However, NHS England told us that the incident was not escalated to its senior management team and Chief Executive until August 2017.21

NHS England told us that, between October 2016 and August 2017, its primary care support team reviewed the correspondence to understand the scale and nature of the issue, but that this “took them a fair while”.22 NHS England had already established a separate National Incident Team (NIT) in March 2016 to process the backlog of correspondence that had been identified in NHS SBS, but the new items of correspondence were not transferred to the NIT until September 2017.23 NHS England told us that the reason for the delay was because most of the correspondence related to current material and NHS England’s response was to try to fix the process that was in place for dealing with such correspondence.24 NHS England recognises that the issue was escalated “rather belatedly internally” and is carrying out an internal review of what went wrong.25

During the period before the issue was escalated, the size of the backlog grew as Capita continued to receive clinical correspondence from GPs in error. Capita and NHS England’s initial checks in November 2016 identified 170,000 items of clinical correspondence, but by November 2017 this had reached 373,868. NHS England estimates that it will cost £2.4 million to review the new backlog of clinical correspondence for evidence of harm caused to patients.26 21 C&AG’s Report, paras 4–5; Q 66 22 Q 67 23 C&AG’s Report, para 3.5 24 Q 69 25 Q 74 26 C&AG’s Report, para 6, 3.8, 3.12 Clinical correspondence handling in the NHS 11